management of primary bone tumours
TRANSCRIPT
MANAGEMENT OF PRIMARY BONE
TUMOURS
DR TELLA A.O.23/01/13
OUTLINE• OVERVIEW• CLINICAL EVALUATION
- History of the patient- Physical Examination- Investigations- Treatment
• FOLLOW-UP• PROGNOSIS• CONCLUSION
OVERVIEW• Bone tumours can be very diverse in
morphology and biologic potential• Most bone tumours are benign (˃95% of
cases)• Malignant tumours may be primary or
secondary- Primary malignant bone tumours are very rare (˂0.2% of all cancers-NCCN)
OVERVIEW
• Most primaries occur in long bones• May be quite difficult to diagnose
specifically• Morbidity and mortality worse in
developing countries• Multimodal approach to management has
improved survival
CLINICAL EVALUATION• High index of suspicion is the first step in
management• Requires a multidisplinary team• Core Group:
- Orthopaedic oncologist- Bone pathologist- Medical/paediatric oncologist- Radiation oncologist- Musculoskeletal radiologist
CLINICAL EVALUATION• Management involves:
○ Meticulous history○ Thorough physical examination○ Prebiopsy radiological evaluation○ Biopsy○ Other relevant investigations○ Staging of the tumour○ Treatment plan
HISTORY OF THE PATIENT● PRESENTING SYMPTOMS:PainMassAn abnormal radiographic finding detected
during evaluation for other conditionsNeurological symptomsPrevious radiation exposureConstitutional symptomsHistory of trauma● AGE OF THE PATIENT – a very important clue
PHYSICAL EXAMINATION
● Evaluation of patient’s general health● TUMOR MASS should be measured & its location, shape, consistency, mobility, tenderness noted● SKIN & SUBCUTANEOUS TISSUE :Small dilated superficial veins overlying the
mass are produced by large tumorsCafé-au-lait spots & subcutaneous
neurofibromas indicate Von Recklinghausen’s disease
PHYSICAL EXAMINATION
● REGIONAL LYMPH NODES: sign of metastatic disease● Atrophy of surrounding musculature ● Neurological deficits ● Peripheral pulses → Adequacy of circulation.● Other systems e.g chest
ALGORITHM
RADIOGRAPHIC EVALUATION
• Plain X-rays• Bone Scans• Computed Tomography (CT)• Magnetic Resonance Imaging (MRI)• Angiography• PET Scans
PLAIN X-RAYS• Provides most useful diagnostic information in
evaluation of bone tumours• Guides the selection of other imaging
techniques• Radiographic parameters are different for both
benign and malignant bone tumours:- Location and nature of the lesion- Periosteal reaction- Soft tissue changes- Matrix of the tumour- pathological fracture
LOCATION OF THE TUMOUR
Geographic patternEx: Most benign tumours
PATTERN OF BONE DESTRUCTION
Non-ossifying fibroma
Unicameral Bone Cyst
MOTH-EATEN PATTERN
Ex: Multiple myeloma, Osteosarcoma
PERMEATIVE PATTERN
Ex: Ewing’s sarcoma
PERIOSTEAL REACTIONS
• Benign tumours:- None- Solid
• Malignant tumours- Codman’s triangle- Sunburst- Onion skinning or Lamellated
Codman’s triangle
Sunburst
Onion skinning
TUMOUR MATRIX
CartilaginousOsteoblasticNo matrix
EXPANSILE LESIONS OF BONE
Enchondroma Fibrous Dysplasia
BONE SCANS• Uses very low radioactive
material like technetium to assess spread to other bones- Polyostotic involvement- Skeletal metastases
• Isotope Thallium-201 used to assess tumour response to chemotherapy
CT SCANS• CT depicts transverse
anatomic relationship of the tumour to surrounding structures
• 3-D reconstruction useful in pre-op planning e.g pelvis
• Helps in evaluation of pulmonary metastases
MRI
• Has better contrast discrimination
• Images can be performed in any plane
• Useful in detecting neurovascular bundles and skip metastases
ANGIOGRAPHY
• Useful in determining relationship of major vessels to the tumour
• Pre-op embolization of a highly vascular tumour can be done prior to surgical resection
ADDITIONAL INVESTIGATIONS
►LABORATORY INVESTIGATIONS:• FBC, ESR, E/U/Cr• Serum Cacium & Phosphate• Serum electrophoresis • Urinary Bence Jonce Protein estimation
DIFFERENTIAL DIAGNOSES
DIFFERENTIALS
BIOPSY
• Tissue sampling for pathological evaluation• The planning and technique is important
- Error may have negative impact on survival• Biopsy of bone tumours can be done open or
closed- Needle biopsy to be done with image guidance
• Patient should be well prepared
BIOPSY • The smallest longitudinal incision compatible with
obtaining adequate sample should be employed• Knife and bone curette should be used to avoid
crushing the specimen• Small circular holes minimise stress risers on the bone• Meticulous haemostasis must be maintained
- Careful use of tourniquet• Exposure should violate one compartment• Drain to pass through incision wound• All biopsies must be cultured and vice versa
BIOPSY
Enneking surgical staging system
STAGING OF THE TUMOUR
TREATMENT
• INITIAL RESUSCITATION- Anaemia to be corrected- Pain control- Antibiotics
• Palliative treatment for metastatic disease
TYPES OF TUMOUR EXCISION
CURETTAGE OF BONE TUMOURS
• Used for benign active tumours e.g unicameral bone cyst, aneurysmal bone cyst, giant cell tumour
• The technique involves creating a window and ‟scooping” out the tumour
• The bony defect created can then be reconstructed using bone graft, PMMA or biologic fillers
• Cryosurgery (use of liquid Nitrogen) is often used to kill remaining tumour cells
CURETTAGE OF BONE TUMOURS
AMPUTATION• Involves the removal of the entire bone and soft
tissues at a safe proximal level to the tumour• Often indicated in complex tumours with
neurovascular compromise and tumours complicated with infection and severe soft tissue compromise
• Requires careful planning : - patient’s goal and expectations- Oncologic and functional outcome
• May entail intralesional, marginal , wide or radical excision
AMPUTATION
LIMB-SPARING PROCEDURE
• Currently being employed due to advances in imaging modalities and availability of tumour prosthesis
• Requires patient preparation, staging studies, adequate biopsy, pre-op and post-op chemotherapy
• Phases of operation:○ Tumour resection○ Skeletal reconstruction○ Soft tissue reconstruction
REQUIREMENTS
• No major neurovascular involvement
• Wide resection of affected bone and cuff of normal tissues
• Resection of bone 3-4cm beyond abnormal uptake on bone scan
• Complete soft tissue coverage
• Contraindications:1. Major neurovascular involvement2. Pathologic fractures3. Inadequate biopsy4. Tumour complications e.g infection, muscle necrosis5. Skeletal immaturity
METHODS OF SKELETAL RECONSTRUCTION
• Autograft (vascularised)• Allograft (Osteoarticular)• Modular endoprosthesis• Allograft-prosthetic composites• Expandable prosthesis• Rotationplasty• Arthrodesis• Limb lenghtening
ROTATIONPLASTY
LIMB-SPARING VS AMPUTATION
• Survival of the patient• Functional outcome• Complications• Psychological factors• Cost
CHEMOTHERAPY
• Effective multiagent chemotherapy has improved overall survival of patients
• Could be given as Noeadjuvant or Adjuvant therapy• Neoadjuvant chemotherapy avoids tumour
progression and decreases tumour spread at time of surgery
• Not very useful in cartilaginous and low-grade tumours
• Patient must be well prepared• Response to chemotherapy needs to be measured
RADIOTHERAPY
• Most primary malignant bone tumours are relatively radioresistant
• Useful in multiple myeloma, Ewing’s sarcoma, spinal tumour
• Brachytherapy or EBRT employed
FOLLOW-UP CARE
• Aim is to detect local recurrence or metastatic disease
• Patients are seen at regular intervals after completion of initial treatment
• Entails adequate assessment of the patients- Physical examination- Lab investigations- Imaging studies
• Long term complications of treatment also evaluated
CONCLUSION
• Treatment of MSS tumours still expanding• Results better with dedicated centres
- Multidisplinary team- Research oriented- Tumour registry
• Early detection and appropriate treatment remains the key in reducing morbidity and mortality
MANY THANKS